Thoughts: Cognitive Restructuring and Reappraisal
Although, as therapists, we come from various therapeutic backgrounds and use different methods and modalities in our work, it's safe to say that we all use cognitive restructuring or reappraisal to one degree or another. As you are no doubt aware, cognitive restructuring or reappraisal are the act of reevaluating and reconsidering one's thoughts, beliefs, and perspectives. These techniques are a fundamental aspect of most therapeutic approaches and whether we realise it or not, most of us incorporate some form of it, in our therapy sessions.
Delving into all the nitty-gritties of how to apply cognitive restructuring or reappraisal is outside the scope of this course, but we will discuss a few key aspects related to its use and explore how we could use it most effectively.
Substituting vs re-evaluating
When it comes to methods of reappraisal, there are two main schools of thought:
Traditional Cognitive Restructuring: This approach involves challenging "thinking errors" by replacing them with more rational or accurate thoughts. The focus is on substituting or replacing thoughts with healthier alternatives.
Evidence-Based Cognitive Reappraisal: This approach places emphasis on evaluating thoughts against available evidence and considering alternative perspectives. Therapists help clients develop critical thinking skills by examining the accuracy and validity of their thoughts. Instead of solely prescribing alternative thoughts, this approach encourages clients to engage in a process of evidence-based evaluation. Furthermore, instead of replacing or substituting thoughts, clients organically arrive at alternative conclusions through this process of re-evaluation.
Traditional cognitive restructuring techniques have faced certain criticisms over time. Some of these criticisms include:
Superficial Treatment: Critics argue that traditional cognitive restructuring techniques can focus solely on changing surface-level thoughts without addressing deeper underlying beliefs or core schemas that contribute to cognitive distortions.
Overemphasis on Positive Thinking: This is one that I personally feel quite passionate about. Research consistently highlights that experiential avoidance, which is the act of suppressing or avoiding distressing thoughts, emotions, or sensations, can lead to increased psychological distress, reduced well-being, and hinder personal growth. Studies underscore the importance of facing and accepting challenging experiences, as avoidance tends to prolong emotional suffering and contribute to the persistence of mental health difficulties. Naturally, this means that we need to approach with caution any therapeutic approach that pushes us away from our real feelings and encourages avoidance. Critics suggest that the emphasis on replacing negative thoughts with positive ones might oversimplify complex emotional experiences and potentially lead to a pressure to always think positively. This approach could downplay the importance of fully experiencing and validating one's emotions. The term 'toxic positivity' has emerged to describe this phenomenon, shedding light on the potential drawbacks of excessive emphasis on positivity.
Focus on Control: Encouraging excessive control over one's thoughts might inadvertently discourage the valuable practice of accepting thoughts as they naturally arise. It could steer individuals towards avoidance strategies, encouraging them to distance themselves from uncomfortable or distressing thoughts rather than developing a healthy relationship with them.
Critics of traditional cognitive restructuring have pointed out that an overemphasis on thought control may inadvertently lead to avoidance of uncomfortable or distressing thoughts. This avoidance can hinder the process of fully engaging with one's thoughts and emotions, which is essential for meaningful personal growth and psychological well-being. Instead, approaches that focus on acknowledging, accepting, and mindfully observing thoughts without immediate attempts to control them have gained prominence as more holistic and effective strategies in therapeutic practices.
In addition, some critics highlight that the emphasis on control over thoughts might inadvertently reinforce a sense of inadequacy or self-blame when individuals struggle to completely control their cognitive processes. My personal observation is that these approaches can contribute to mental exhaustion over time, as people feel a constant need to wrestle with, control, shape or replace negative thoughts.
A seasoned therapist takes a more nuanced and thoughtful approach to cognitive restructuring. Rather than simply prescribing alternative thoughts, a skilled therapist guides clients through a process of evidence evaluation. When we encourage clients to critically assess their thoughts against any available evidence, clients arrive at more helpful and realistic conclusions on their own. This approach promotes deeper insight and equips clients with tools to identify, evaluate and modify their thought patterns independently.
I should clarify that a skilled and experienced therapist can apply Traditional Cognitive Restructuring in a manner that involves guiding clients to evaluate their thoughts against evidence and encouraging deeper exploration, similar to the principles of Evidence-Based Cognitive Reappraisal. The main point of differentiation is that Evidence-Based Cognitive Reappraisal places a particular emphasis on evidence evaluation, which is not always as explicitly highlighted in all applications of Traditional Cognitive Restructuring.
Present and Past Thoughts
While we might not always realise it, the use of cognitive reappraisal or restructuring extends beyond our current thoughts. This transformative process is harnessed by various therapeutic approaches, such as CBT, Schema Therapy, Narrative Therapy, EMDR, Internal Family Systems (IFS) Therapy, Hypnotherapy, and Gestalt Therapy, often integrating imagery work to facilitate healing around past memories and traumas.
And here are a couple of practical examples to illustrate these concepts:
Example 1: Rewriting Childhood Memories
When practicing cognitive restructuring, imagery becomes a potent tool that assists with the exploration of our past experiences. Imagine a client who, as a child, experienced a significant event that left a lasting negative impression. Using imagery, the client is guided to revisit this memory, engaging their inner child. Through compassionate dialogue and reframing, the client's adult self can provide understanding, reassurance, and new interpretations. This process not only reshapes the memory's emotional charge but also fosters a sense of healing and integration.
Example 2: Addressing Traumatic Experiences
Various therapeutic modalities, including EMDR, trauma-focused CBT, and narrative therapy, harness the potential of imagery work to address deeply rooted traumas. Narrative therapy, for instance, encourages individuals to reconstruct and retell their life stories, often incorporating imagery to create a new narrative that empowers them and reframes their experiences. Similarly, in EMDR and trauma-focused CBT, imagery work plays a crucial role in facilitating cognitive shifts and emotional healing by allowing clients to view their traumas from different angles.
Imagination as a Source of Healing and Harm
Imagination can be seen as a double-edged sword, capable of both psychological harm and benefit. Often, we may not fully realise the immense power that our imagination holds in shaping our emotional experiences and psychological landscape. So, let's take a closer look at this.
Imagination and Psychological Harm: In our formative years, imagination plays a significant role in shaping our beliefs about ourselves and the world. According to Karen Horney's theory, “the idealised self” is born when a child uses their imagination to create a perfect idea of who they should be. However, this imagination can turn into an unrealistic expectation, leading to feelings of inadequacy, anxiety, and self-criticism later in life. Such maladaptive use of imagination can create a host of future issues that impact mental well-being.
Additionally, scholarly research has shed light on the potential risks of excessive or maladaptive fantasising, which involves the creation of intricate mental scenarios often for the purpose of escaping reality or wishful thinking. Studies have indicated that chronic fantasising may correlate with increased levels of anxiety, decreased psychological well-being, and difficulty in managing negative emotions (Smith et al., 2018; Soffer-Dudek, 2018). This highlights the delicate balance between the creative potential of imagination and its potential to contribute to psychological harm.
Positive Use of Imagination in Therapy: On the other hand, when we purposefully engage in imagination during therapy, we unlock its potential as a powerful tool for positive change. Imagery work allows us to tap into the creative depths of the mind, encouraging clients to explore alternative perspectives and cultivate more balanced and rational thoughts.
While there are many techniques for the use of imagination in therapy, our main goal is usually this: to travel with the client to a specific time in the past or future and then to help them see events or their understanding of the events in a new light. A good practice is to inform the client that although we can't change the past, that what's done is done, through this exercise can change how those events affect them now. In other words, by imagining the past differently, we might feel different emotions, and that can extend to how we feel today.
Stay tuned as we have some practical examples and case studies lined up in the next section, to help you develop a real grasp of how to apply cognitive appraisal and imagery exercises for various mental health conditions.